Treatment Desired Outcomes

The goals of therapy for streptococcal pharyngitis are to eradicate infection in order to prevent complications, shorten the disease course, and reduce infectivity and spread to close contacts. Antimicrobial use only prevents peritonsillar or retropharyn-

geal abscesses, cervical lymphadenitis, and rheumatic fever. Immune-mediated, nonsuppurative complications of streptococcal infection that are not impacted by antimicrobial treatment include acute glomerulonephritis, reactive arthritis, and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infection (PANDAS) that commonly presents with obsessive-compulsive or tic symptoms fol-

33 38

lowing streptococcal infection. ' Pharmacologic Therapy

Antimicrobials should be used only in cases of laborator y-3 documented streptococcal pharyngitis associated with clinical symptoms in order to avoid overtreat-ment33,3 ,37 (Fig. 72-5). Effective therapy (Table 72-5) reduces the infectious period from approximately 10 days to 24 hours and shortens symptom duration by 1 to 2

days. Treatment guidelines recommend penicillin as the drug of choice because of its narrow antimicrobial spectrum, documented safety and history of nasopharyn-

33 37

geal streptococcal eradication, and low cost. Studies proving that antimicrobials prevent rheumatic fever used intramuscular procaine penicillin, but other antimicrobials can also eradicate nasopharyngeal streptococci and presumably are effective for preventing rheumatic heart disease. 7 organisms that inactivate penicillin, improved eradication of commensal streptococci that are protective against group A streptococcal disease, and improved pharyngeal tissue penetration of cephalosporins. Usual duration of therapy is 10 days, but evidence is mounting that 5-day courses of certain cephalosporins are just as effective for bacterial eradication as 10 days of penicillin.40

Table 72-5 Antibioticsa for the Treatment of Streptococcal Pharyngitis

Dfug

Adult Doie

Pfctintfir Dot.»

Durilion

(tmmmtf

Penicillin Y

lifl mn 3-1 ilme* dally

Í5Q mg ï-î rim*, riafy. íiOV nvi

íOdayí

Oiiiioirhrtrp but inct^sirtt)

of 500 mg twice daily

hwire daily (over 12 years)

tepofIs- ct treatment lafluiei

AenkiBln t.

1.? nWfcMi unli?

bOQODO unit-; (tf mfidrt }) Ikií

1 Meto»

Useful for nonadhetence at

beniitllikw

em™* painful in|etl¡o<i

Amoakilbn

150 mc| 3 limes daily of

500 my [mneddilK Jifl-1,500 ruin oncic daily being studied

40-5Û mg/kg/daiy In 2-1 ctoses

10 dap

Preferred over penk'hn V ñof yuung ( hitjn^i imomL paidlíbte)

Cephalexin

M0- 500 mg 1 limes da»y

Jh SU mg/bgvday In t ctoies

10 days

Consldef in penicillin allergy iif nontype 1 reaction)

Cefadroxil

500 mg 1 wire dally

io mgitgvtiay In 1 dmes

10 days

CefuHMnw acetl

mg iwioxbily

JO nvj/lijAi^ In 2 SCi".

lOdíyí

600 rflij iVtce Ltiily

!4 in^tti/Jay in 1-Î ctosei

5-10dayi

Buhcí spec Liuny expensive

*¿Wwo<nyn¡(»

500 mg duily

1Í mtyiig mite daily

5 (Jam

lnciejMi>g rtVildnte

Clindamycin

150 mt; 4 urn«, rtaily

JO-3Ó mg/kqiday in 3 [toses

10 dap

Useful for lecuuent Iníet tlan-L

ÏJlhet fCÍA .ippfowd ageriK inclucl^ .vnofticlllln claviianale, cufióme, cefaclor, ceípfmL cefpodonlme, flfylNofnyrln.clariihiamjfin, and othei\.

ÏJlhet fCÍA .ippfowd ageriK inclucl^ .vnofticlllln claviianale, cufióme, cefaclor, ceípfmL cefpodonlme, flfylNofnyrln.clariihiamjfin, and othei\.

FIGURE 72-5. Treatment algorithm for management of pharyngitis in children and adults. "Rapid antigen detection tests (RADTs) are preferred if the test sensitivity exceeds 80%. ^Parents, teachers, or other adults with significant pediatric contact should also be cultured if RADT is negative. (From Refs. 36, 37.)

FIGURE 72-5. Treatment algorithm for management of pharyngitis in children and adults. "Rapid antigen detection tests (RADTs) are preferred if the test sensitivity exceeds 80%. ^Parents, teachers, or other adults with significant pediatric contact should also be cultured if RADT is negative. (From Refs. 36, 37.)

Patient Encounter 3

A 7-year-old boy presents to the pediatrician with a sore throat and fever of 39.2°C (102.6°F) for 24 hours. His mother reports that other children in his class have had "strep throat" recently. He also complains of pain on swallowing and is not eating or drinking very much. He does not have any other symptoms and has no known drug allergies. Physical examination reveals pharyngeal and tonsillar erythema with exudates and painful cervical lymphadenopathy.

Does this child have streptococcal pharyngitis?

Is antibiotic therapy indicated? If so, what agent should be initiated andfor how long? What education should be provided to his mother regarding treatment?

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